Healthcare Provider Details

I. General information

NPI: 1508962994
Provider Name (Legal Business Name): HEALTH SOURCE DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 02/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 STATE ST
CAMBRIDGE MN
55008-5033
US

IV. Provider business mailing address

PO BOX 64979
SAINT PAUL MN
55164-0979
US

V. Phone/Fax

Practice location:
  • Phone: 763-689-7306
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MR. ROD L. KORNRUMPF
Title or Position: ADULT MENTAL HEALTH ADMINISTRATOR
Credential:
Phone: 651-431-5003